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Background: Transplantation medicine is an example of medical interaction between different sectors and institutions of care. The course of treatment includes not only trans-institutional and -sectoral care structures, but also the integration of several specialist disciplines. A patient on the waiting list for kidney transplantation has contact with for example cardiological, pneumological, urological, gastroenterological, endocrinological, vascular or hemic specialists. However, due to problems at the interfaces of the different health care sectors as well as interruptions in treatment and a lack of information flow, the implementation of a patient-centered and continuous treatment is difficult. The decline in the number of donors due to the transplantation scandal in Germany in 2012 has demonstrated the vulnerability of the area of transplantation and donation: In 2011 there were 1,200 organs donated, compared to 864 in 2014. Approach : The Hannover Medical School (MHH) has the largest transplant program in Germany and one of the largest in Europe, with about 350 transplantations after deceased donation in 2014. In terms of lung transplantation, the MHH is leading worldwide. In 2014 for example, 130 lungs were transplanted. Since 2008, the Integrated Research and Treatment Center Transplantation have been supported at the MHH by the Federal Ministry of Health. The aim is to integrate all basic and clinical departments which are involved in transplantation to an effective unit, to develop new diagnostic and therapeutic strategies, as well as supporting patient centered research and treatment. Based on about 83 post mortal and eight living donated livers in 2014, experts developed a clinical pathway including involved institutions and each single treatment step. Thereby different success-factors could be derived. Propositions : Exchange of Information: It is of particular importance that a continuous cross-sectorial treatment is supported through a process and information technology link. An integrated exchange of information between decentralized stakeholders and institutions is essential in order to avoid ambiguity and prevent information loss. It is discussed to unify and merge the transplant data in the context of a national transplant register. The focus is on increased efficiency in the documentation or integration of different data sources, respectively to an improved documentation and data flow harmonization. Funding: The financial pattern during the transplantation treatment process includes various forms of compensation. The GPs and further specialists, the inpatient or rehabilitative care and medical prescriptions are all reimbursed through different schemes. However, separate pattern of finance as well as own budgets between sectors inhibit inter-sectional collaboration. Possible compensation forms for overcoming the organizational separation of the sectors are bundled payments. These are based on a defined package of services, which are generated in the context of a specific episode of care and are paid prospectively by lump sum. Thus, this kind of compensation includes not only separated care sectors, but all the stages within the supply chain. Leadership: The complex care structures of transplant patients as well as the important role of the public trust into the transplantation system need a holistic management of the process. The development of strategies, their communication and the involvement of any stakeholders are management tasks. In healthcare, this appears to be a particularly difficult task as the focus is on entire organizations rather than on classical organization. Concerning the transplantation process with a variety of cross-sectoral and -institutional interfaces, this task is even more difficult. Thereby, it is very important to delegate medical tasks, rather than substitution. In this context one issue is for example to integrate a case management for the patient. Discussion : The structures of care in the field of transplantation present a variety of complicated paths and hurdles for the patient. Besides challenges concerning the involvement of different sectors of care and of several institutions, there is no so-called owner of the process for the patient. It is neither clear who is in charge for the patient, nor exits a guide through the system. Thus, it should be focused to support a holistic course of treatment with a patient-oriented coordination of care, with help of the already mentioned options. However, the German health system barely satisfies the high demands which are accompanied by chronic and mostly complex conditions and moreover hampers appropriate supply routes. In this context, there is a need for an inter-sectorial treatment path, in terms of an integrated care concept.

Interfaces between trans-institutional and trans-sectoral care structures - Pathways in transplantation medicine